six months of MEDICARE

...After its initial exhilaration over the unwonted defeat inflicted on the medical establishment with the passage of the Medicare program, the Johnson Administration began to worry that it might not be able to deliver the goods without mollifying the doctors and the hospitals...

...Still to be devised are some means for curbing the extravagances of the solo practice of medicine with its needless waste of personnel and equipment and lack of effective surveillance of quality...

...The cheerful reports from Medicare headquarters in Baltimore have been that the program is running more smoothly than expected and all concerned are fully cooperating...

...In effect, this means that doctors can now charge whatever they please for patients who formerly were often treated gratis or at reduced rates...

...Unfortunately, there is good reason to believe that many hospital utilization committees still exist largely on paper and that it will take major changes in the prevalent organizational setup of medical staffs to turn them into effective instruments...

...President Johnson announced last October that he will recommend extension of Medicare coverage to the more than one million persons under the age of sixty-five who are currently receiving Social Security disability benefits...

...No great rush of aged patients into hospitals developed at first, at least partly because the program was initiated during what are traditionally low-occupancy months...

...They have been equally disillusioned as they have watched the Social Security Administration bend over backwards not to antagonize the medical profession and the hospitals in drawing up the operational regulations for the program...

...The powerful drug lobby may therefore be expected to stage a last-ditch battle against a mandatory provision for generic prescriptions in Federal health programs...

...They have discovered that they can not only live with Medicare but can clean up under it, as is amply demonstrated by the rash of fee increases put into effect during the past year throughout the country...

...But what has been happening lately to hospital charges and doctors' fees, which is certain to be rapidly reflected in Medicare costs, has been causing visible concern in Washington...

...Numerous hospitals have put into effect increases in room rates ranging from five dollars to ten dollars a day, and charges of fifty dollars a day exclusive of the cost of ancillary services are now common...

...These are defined as "the customary charges for similar services generally made by the physician and the prevailing charges in the locality for similar services...

...But it would be only a first step in the direction of coordinating our hospital system and eliminating the wasteful duplication of facilities and equipment and the neglect of alternative and more economical services...

...All in all, the suppliers of medical and hospital services have every reason to be delighted by the way things have worked out...

...The inefficiencies of the voluntary hospital system and of the solo practice of medicine have been left untouched...

...The high-level investigation of medical care costs recently undertaken at President Johnson's direction was an obvious expression of the Administration's concern and is viewed by competent observers as more of an attempt to head off a Congressional probe of Medicare than a real effort to get to the bottom of the situation...

...The doctors, on the other hand, have found that their fears of Medicare as the beginning of the end of the private practice of medicine have been groundless, for the time being at any rate...

...The prospects for changes in the Medicare law are obviously affected by the more conservative complexion of the incoming Congress and closely tied up with the cost picture...

...Strong Congressional sentiment was reported last year for expanding Medicare's present in-hospital-only drug benefits to cover the prescriptions needed outside by older patients, at an estimated added annual cost of nearly $400 million...

...Advocates of generic drugs claim that their use would cut costs by anywhere from twenty to forty per cent...

...The impact of whatever controls are provided in the Medicare law has been considerably softened by the fact that in most places Blue Cross and Blue Shield, with their close ties with the hospitals and the medical profession, have been designated as administrative agents for the program...

...The larger aim of the proponents of generic drugs is to reduce costs for all consumers by increasing competitive pressures on the brand-name manufacturers...

...While the annual rise in hospital costs has averaged seven per cent in the 1960-65 period, the rate of increase was much higher last year and several leading authorities have predicted that such costs are likely to jump in 1967 by anywhere from twenty to thirty per cent...

...If properly carried out, this function can become a potent educational tool and implement, in the broadest terms, the provision of the law for "promoting the most efficient use of available health facilities and services...

...Senator Anderson has drafted a bill for the control of the expenditure of such funds by Federally-aided state planning agencies as a means of preventing their use for unnecessary duplication of plant and equipment...

...With a few notable exceptions, they failed to do so and thus tended to freeze all the inefficiencies of the existing structure of our medical institutions...

...This proposal may not encounter much opposition as the disabled already are entitled to medical benefits under Title 19 of the Social Security Act, the so-called medicaid program, which is jointly financed by the state and Federal governments...

...Generic drugs are generally marketed by smaller drug houses, and they sometimes cost only one-third as much as their brand-name equivalents...

...The requirement in the Medicare* act that all participating hospitals have arrangements for regular utilization review to guard against excessive lengths of stay has great potential not only for economies in the use of beds and various medical procedures but also as a vehicle for more effective supervision of the quality of care in which the medical staff systematically participates...

...Despite its limited financing, the program just getting under way for regional centers for the diagnosis and treatment of heart disease, cancer, stroke, and related conditions holds out far-reaching potentialities for improvements in the training of clinicians and the care of patients...

...Senator Long, who plans to hold hearings on his bill soon, has argued that the government should not be required "to subsidize the exorbitant profits enjoyed by the major drug companies by buying their brand-name products at such excessive markups...

...This will take not only money but creative imagination and the courage to challenge the vested interests of the medical establishment...

...The Medicare statute also attempts to discourage excessive dependence on hospitalization by seeking to promote a more appropriate use of medical resources tailored to the needs of patients...

...The alacrity with which doctors have been jacking up their fees spells equally bad news...

...Since the aged are hospitalized longer on the average than younger patients, they account for an even greater proportion of patient days...

...The program's emphasis on the collaboration of health services on a regional basis and its flexible provisions for a wide variety of demonstration projects should allow fruitful experimentation with new ideas...

...Federal grants were recently awarded for four demonstration multiphasic screening projects, and there has been other evidence that the U.S...

...Multiphasic screening for the early detection of disease has long been advocated by many medical authorities and has been used with great success by the Kaiser Foundation Health Plan...

...six months of MEDICARE by SELIG GREENBERG A t the end of its first six months of operation, the Federal Medicare program finds itself in the curious position of having disenchanted many of its original backers and refuted most of the fears—real or professed—of its bitterest opponents...

...Serious obstancles are posed by the failure of hospitals to provide more economical facilities for convalescing patients who do not require all of the costly services needed by the acutely ill and by the poor quality of many of the existing nursing homes for chronic patients...

...This issue, more than any other, will shape the future form of the organization of health services in this country...

...Fiscal aides of the Senate Finance Committee are reported to believe that Medicare costs may run as high as double the original estimates...

...The most promising approaches toward greater economy as well as better quality in the health care field lie in a more effective deployment of existing manpower resources, through wider resort to group practice and utilization of auxiliary personnel, and a more balanced use of facilities through a coordination of the whole spectrum of medical services which would put less emphasis on expensive hospitalization...

...Whatever happens to the Harrison-Fogarty bill at this session, a national program for preventive medicine is an urgently needed venture and is bound to come before long...

...Doctors are guaranteed payment of "reasonable charges" for treating Medicare patients...

...Such predictions give the Social Security Administration's actuaries the jitters, portending as they do a staggering Medicare hospital bill...

...The hospital reimbursement formula guarantees payment of costs without any effective controls over what is included, plus allowances for depreciation and an additional two per cent for improvement of services...

...With the help of heavy promotion, brand-name products marketed by the big pharmaceutical companies now capture most of the retail prescription drug sales amounting to $3.4 billion a year...

...Both substantively and administratively, the bite of what has been portrayed as the entering wedge for the bugaboo of "socialized medicine" has proved much milder—for doctors and hospitals—than its bark...

...The political inadvisability of such a far-ranging examination at this time in no way detracts from the fact that it would address itself to what is probably the foremost single issue in the medical care field—the efficiency and capabilities of the medical industry...

...While Medicare does offer some opportunities along this line, it still remains to be seen how vigorous the government will be in overcoming the great obstacles which stand in the way of their implementation...

...Senators Long and Clinton P. Anderson of New Mexico, one of the earliest advocates of Medicare, also are pressing for tighter controls on the reimbursement for hospital services...

...But they represent an invitation rather than a mandate...

...The transfer of the disabled under the age of sixty-five from Title 19 to Medicare may fit in with Congressional plans for tightening up the medicaid program, which as it now stands sets virtually no ceiling on Federal expenditures...

...By the very nature of the program, the initial experience with it was bound to prove somewhat anticlimactic...

...In their anxiety to get the show on the road by the deadline of last July 1, top officials of the Department of Health, Education and Welfare proceeded to enter into operational agreements which give the professional organizations just about everything they want...

...For despite the extravagant claims made on both sides of the prolonged debate which preceded enactment of Medicare, it has turned out to be neither the panacea pictured by its more ardent proponents nor the ogre dreaded by organized medicine...

...Facing an uncertain fate in the new Congress is the so-called preventicare bill sponsored by Senator Harrison A. Williams of New Jersey and Representative John E. Fogarty of Rhode Island, both Democrats, for regional mass health screening programs for all Americans over the age of fifty...

...Skyrocketing costs will tend to act as a brake on proposals for expanding Medicare benefits and coverage, particularly since the President and both parties already are committed to put through this year a substantial increase in Social Security benefits which will require a boost in taxes...

...Such an effort would require the tackling of causes rather than symptoms to determine whether unwarranted inflation of health charges can be reasonably contained through a more rational organization of hospital and medical services and would unquestionably mean stepping on many toes...

...The implications of the generic versus trade name controversy go far beyond the government-subsidized medical programs...

...The bills have been coming in slowly because of administrative kinks which are gradually being straightened out and, in the case of the supplementary medical care section of the act, because the $50 deductible must be met by the patient before he can start qualifying for benefits...

...Public Health Service plans to put increasing stress on fostering improvements in the delivery of health services...

...Such a provision would constitute a long-overdue move toward attempting to impose some controls on the components which go to make up the costs of health services...

...Both Senators have taken exception to the Medicare allowances for depreciation of hospital buildings and equipment and for improvement of services...

...The supporters of Medicare quickly discovered that its benefits are enmeshed in a thicket of limitations, deductibles, and shared payment provisions, and cover only about half of the average medical costs of the aged...

...But the Medicare admission rate has been steadily rising and is now estimated to be running at nearly 100,000 a week, which is close to twenty per cent of all admissions...

...Only the medical profession, the hospitals, and the various public and private health agencies can take advantage of the opportunity and translate it into reality...

...Partly as a direct result of the inflationary impact of Medicare, and in part because pressures by nurses and other employes for higher pay scales happened to come to a head at the same time, the spiral of.hospital costs has gone up sharply in recent months and is expected to keep on climbing...

...The only ones who are discomfited are the consumers who, unlike the doctors and the hospitals, have no vigorous lobbyists to champion their interests...

...It is high time indeed to supplement the huge government investment in medical research with practical measures for making the fruits of this research more rapidly and widely available to patients...

...While the aged have unquestionably benefited from Medicare, though nowhere near as much as they had hoped for, its far-reaching inflationary effects mean higher health care bills for the rest of us...

...This is done through the provision for coverage of outpatient hospital services, physicians' services in the home and office, services in facilities for recuperating and chronic patients, and home care services...

...Although the hospitals are grumbling about the mounting volume of paper work entailed in handling Medicare patients, their financial base has been immeasurably strengthened by the cost-plus reimbursement arrangement which they are now guaranteed by the Federal government...

...But the high Medicare costs will tend to bolster the case for tighter controls on the providers of medical and hospital services...

...The continued price inflation in our medical economy is soon likely to confront the Administration and Congress with the unhappy prospect of having to choose between another increase in the already steep schedule of Social Security taxes or dipping more deeply into general revenue to supplement the financing of the Medicare program...

...These provisions open the door toward integration of the fragmented pattern of our health services into a sequential system of balanced care...

...In underwriting a substantial portion of the nation's medical expenditures, the framers of the Medicare law had a unique opportunity for bringing some order into the anarchy of our health care economy...

...Already pending in the Senate is a highly controversial proposal by Senator Russell B. Long of Louisiana, chairman of the Senate Finance Committee, to require doctors to prescribe drugs under all Federally-financed programs by their generic or chemical names rather than by the advertised brand names which usually cost much more...

...Enactment of such a plan, which would triple Federal expenditures for drugs under Medicare and welfare medical aid programs, would add fuel to the battle shaping up in Congress over government procurement policies in the drug field...

...This failure not only poses a threat to the fiscal integrity of the Medicare program itself but is bound to have seriously adverse effects on the entire medical economy...